One major reason why mortality is 20 times higher during volunteer anesthesia missions in the developing world relates to equipment. Volunteer anesthesia equipment hazards include using old, poorly maintained and often unfamiliar equipment in a foreign, stressful environment. Mistakes and accidents easily occur. Prevention requires preparation, vigilance, and often, ingenuity.
Common volunteer anesthesia equipment and supply issues include:
- unfamiliar devices/agents
- malfunctioning, poorly maintained equipment
- unreliable oxygen supply
- scarce or contaminated intravenous fluids
- unreliable electrical supply
- conservation/recycling/re-sterilization of supplies
Anesthesia vaporizers, circuits and machines offer enormous potential for patient injury.
Local vaporizers are often old, poorly calibrated, and occasionally glued stiff by thymol deposition after years of abuse. Expect to determine MAC on the vaporizer during the first few cases. Observe patients carefully. Typically vaporizers deliver far less than the gauge says, but the reverse can also occur. You may encounter vaporizer types as well as breathing circuits and machines totally unfamiliar to you.
For a more detailed discussion of risks associated with vaporizers, older agents such as Halothane, and unfamiliar breathing circuits see Part 1 of this series: Halothane: Avert Volunteer Anesthesia Mishaps 1.
Malfunctioning, Poorly Maintained Equipment
Volunteer equipment hazards include unfamiliar anesthesia machines that may have leaking valves and gas lines. Broken parts may or may not be visible or apparent. The machines may have a disconcerting tendency to fall apart. Foreign manufactured machines may be thoroughly unfamiliar, with incomprehensible labels on the controls.
The mission was in Honduras in a small charity hospital literally in the middle of a bean field about 200 miles from the nearest large hospital. Up until now, all the patients had been children for cleft lip repairs when a young man arrived with a deep machete wound to the forehead. The wound had peeled open his frontal sinus. Our Head and Neck surgeons felt it needed urgent repair to prevent brain abscess or meningitis. Although he had walked to the clinic, he was clearly concussed and I was concerned he might have decreased cerebral compliance. No advanced imagery or CT was available. Wanting to minimize the risk of increased intracranial pressure, I planned hyperventilation following rapid sequence induction with a large dose of pavulon and pentothal. However, as soon as I administered the first breath with my ancient Foregger machine, the common gas flow bar popped out of the machine and rolled under the OR table. Pandemonium ensued. Being unable to now ventilate my newly paralyzed and intubated patient, the surgeon had to perform mouth to tube ventilation until I reassembled the machine. The only ambu bag had been left behind in the farmhouse. Fortunately, the patient did well.
The local nurse who worked at the site later told me that the machine had a broken gasket that allowed back pressure into the machine with large tidal volumes. The bar sometimes popped out when ventilating adults rather than children. As long as one was “gentle” giving a a large tidal volume” it worked fine. Had I asked about the machine earlier, I no doubt could have avoided the whole near miss.
For a more detailed discussion with a suggested algorithm for changing machines mid case, see: Help! My Anesthesia Machine Is Not Working
Be prepared for abrupt machine or oxygen failure — keep your manual self-inflating ventilation bag close at hand. It should be self-inflating in case your machine loses the ability to give positive pressure ventilation.
An 18-month-old suffered brain damage and eventual death following a cardiac arrest during cleft lip repair. Unknown to the anesthesiologist, the anesthesia machine had a broken flush button. Pressing the flush button at an angle locked gas flow on at 70 psi for several seconds until the circuit could be broken. The child initially appeared fine. However, 30 minutes later the child arrested. Following a prolonged resuscitation effort, bilateral tension pneumothoraces were discovered and treated. Congestive failure, hypoxia, and brain damage were at this point present and the child died one week later despite intensive care. The probable mechanism for flush button failure was likely due to a spiral fracture of the plastic shaft that transmits the finger pressure to open the valve. Read another case report of broken flush button failure on a modern machine: Oxygen Flush Valve Booby Trap
Hazardous Machine Differences
Foreign machines may also have subtle but potentially dangerous differences such as an oxygen control knob in a different location which is easily confused with nitrous oxide. Tired, on “autopilot” and in a poorly lit room, turning off the oxygen rather than the nitrous is easy to do when the dials are reversed.
Pop-off valves may be rusty. I’ve use a pliers to turn the broken dial on a ventilator to turn it on and off. Older vaporizers are filled by simply pouring the agent (hopefully the correct one) directly into the filler port — no pin indexed spout required.
Each anesthesia provider on your team must understand the function and potential hazards of every machine that the team plans to use. The local anesthesia providers are probably thoroughly familiar with each machine’s quirks. Ask them!
Lack of Scavenging System
The lack of anesthetic gas scavenging systems is an environmental hazard of the Developing World operating room. Unless you vent gases to a hallway or out a window, the anesthetic gases will accumulate over the course of the day. If you can’t vent, take frequent breaks to avoid fuzzy thinking and fatigue.
Consider low flow or closed-circuit anesthesia — however, never use low flow or closed circuit anesthesia with a Bain or Mapleson circuit. An additional risk of the Bain Circuit is unrecognized disconnection or kinking of the inner, fresh gas delivery hose. If this occurs, the entire corrugated limb becomes dead space. The resulting respiratory acidosis is unresponsive to increased minute ventilation. You must check for an intact circuit before use.
Unreliable Oxygen Supply
Is oxygen readily available or must you budget your resources? Will you use tank oxygen or wall oxygen? Even wall oxygen is potentially suspect.
On the first day of the mission in Vietnam, all children spontaneously breathing 100% oxygen and halothane during cleft lip/palate repair experienced hypoxemia. Hyperventilating them with 100% oxygen raised saturations back into the low to mid 90%s range. Following surgery all children had normal room air saturations. We discovered the source of the wall oxygen was an ancient oxygen concentrator. Multiple OR tables operating simultaneously overwhelmed the device, resulting in ever decreasing concentrations of oxygen. With all 8 tables running, we were no doubt delivering room air. to solve the problem, we borrowed oxygen tanks from the local Swedish Embassy to finish the mission.
Blue nitrous oxide tanks are often refilled with oxygen in the developing world since nitrous itself is scarce. This defeats both the international color code and the pin indexing system. An FiO2 gauge will alert you to danger but is often unavailable.
Oxygen regulators and tanks are often very old, occasionally rusty, and may leak or be inaccurate. Observe them carefully and treat them with caution when turning on the tank or switching regulators.
Changing an H-Cylinder Mid Surgery
Ensure certain safety precautions when running an anesthetic on tank oxygen. Check the tank pressure before you start each case. Change it if it’s low. Know where your next tank is before you start. Make sure you know where the tank wrench is and how to use it to change tanks. Use lower flows to conserve oxygen and never waste it. Keep a self-inflating bag available in case pressure suddenly fails — otherwise you might find yourself doing mouth-to-tube ventilation.
If you must change a tank in the middle of a case make sure the patient is deeply anesthetized and, if possible, breathing spontaneously. Close your breathing circuit pop-off to maintain a pressurized, oxygenated system while you or your assistants rapidly change the tank. For details on this technique see: Changing Your Oxygen Tank In The Middle of Surgery
You are unlikely to have small transport oxygen tanks. The two common choices are a small rubber pillow filled with oxygen which leaks out a hole in the side at a slow rate, or a large “H” cylinder on an industrial dolly.
Scarce or Contaminated Intravenous Fluids
Local hospitals may manufacture their own intravenous fluids, raising the possibility of contamination. One hospital I worked at used screw top glass bottles for re-sterilizing and refilling between patients. Have a high index of suspicion if multiple patients develop inexplicable fevers or odd reactions.
When IV fluids are in short supply we often make do with fluid types we would not normally use at home.
10-month-old, roughly 8 kg female baby for cleft palate/lip repair. No lactated ringers was available that day, therefore the anesthesiologist elected to hang 1000 ml of D5W connected to a maxi-dripper instead. Intraoperative course was uneventful. However, in the recovery room the IV “got away” and the child received a 600 ml bolus of D5W over 1 hour. Seizures occurred. Diagnosis presumed to be iatrogenic hyponatremia, although electrolyte determination was unavailable. The team slowly titrated NSS over the next 12 hours. The patient recovered by the next day and did well. The volunteer group subsequently established guidelines for use of D5W when IV fluids were limited.
D5W Use Guidelines
If D5W required on some cases due to supply constraints, limit it to:
- older patients,
- patients having non-blood loss procedures,
- patients in the early morning (less likely to be dehydrated),
- use minidrips or volutrols if a large bag must be used on a small child, or remove some volume from the bag.
Save LR/NSS type solutions for :
- smaller patients,
- dehydrated patients or patients done later in the day,
- blood loss procedures;
Do Not Reuse Discontinued IV Setups
Don’t reuse discontinued IV bags on a different patient by changing IV tubing if supplies run low. Blood can easily track up the line by gravity flow if the bag is ever lower than the head, potentially contaminating the entire bag.
“Shared” I.V. Boluses
I have divided an otherwise uncontaminated IV bag between patients by using separate 20-50 ml syringes/needles and sterile technique within a 24 hour period. This proved especially helpful when providing a small bolus of D5W or D5LR to small, NPO, often malnourished patients done late in the day to avoid hypoglycemia.
Blood supply in the developing world may contain hepatitis, AIDs, malaria, and other infectious diseases. If more bolus is required, do not re-enter the “shared” bag/tubing with the same syringe once you have penetrated the patient’s IV line. Get a new syringe.
Intravenous catheters may be limited. Use sizes judiciously. Don’t be left with 24 g catheters for your adult population or have only 16g’s for your infants.
Unreliable Electrical Supply and Shock Hazards
Power in the Developing World is unreliable. Brown outs and black outs are common and can occur at any time. It’s common for the local population to illegally tap into power poles, overloading the system. Carry a flashlight. Have battery backup for all essential electrical equipment if possible.
Foreign current is often 220 volts as opposed to 110. Many foreign hospitals compound the problem by having both types of circuits in the same wall to accomodate a mix of equipment. If this is the case identify each socket with a label to prevent accidentally blowing out your equipment or the hospital fuse.
Test each socket ahead of time for function. The hospital engineer can often help, but you can also test with something as simple as a table lamp. This step also prevents accidental discharge of the backup battery without your knowledge, with sudden failure of your equipment. Rarely, the sine wave of the current will vary enough that rechargeable batteries will not recharge, even with the appropriate converters.
Room lighting and OR lights may be marginal. Carry a flashlight. Consider head lamps with battery backup. Many ORs in the Developing World depend on windows to provide ambient light during the day. The OR in the following photos had banks of windows along the ceiling — great during the day, not very helpful at night.
Use caution in the overzealous use of adapters, converters, cheater plugs, and extension cords. There is no line isolation. The micro and macro shock hazard to the patient and the operating room team is very real, especially with outdated or damaged equipment. Avoid patient contact with metal.
You will frequently need to share suction with the surgeon. With frequent electrical blackouts, you will intermittently lose your suction machine. Turning the patient lateral and placement in trendelenberg are additional methods to protect the airway from aspiration when suction is not available.
Reusable grounding pads are common. Ensure good patient contact with the bovie pad. Don’t allow fluids to pool under the patient or on the floor. Look for frayed cords and damaged equipment. Beware fire hazards. Drapes and gowns in developing world are not fire retardant. Flammable liquids and gases may be present. Fire extinguishers may be in short supply, or outdated.
Hospitals in the Developing World can’t afford the luxury of single use items. Scarcity of supplies may force you to conserve, clean, and re-sterilize everything from suction catheters to endotracheal tubes. The local hospital may already recycle everything, including patching and cleaning surgical gloves, resharpening needles, and cleaning syringes.
Set up your workroom so that needed supplies are easily located. Inventory extensively, since you may not have packed your own supplies. Remember to save any shipping material you will need for repacking.
Learn how your site cleans equipment.
Any technique must minimize infectious disease spread, among your patients and to your team. Equipment and supplies are frequently soaked in Cidex when autoclaves are not available. If so, meticulously flush with sterile water to avoid chemical tissue burns, especially airway burns. Boiling works well for uncuffed endotracheal tube but degrades cuffs quickly.
While in Honduras, our local hospital hand washed anesthesia circuits, masks and bags. They then hung them in an outdoor minimally vented shed and exposed them to high ambient ethylene oxide gas overnight. Needless to say this was a fairly hazardous procedure.
Be Prepared To Repair
The volunteer to the Developing World must be prepared to repair just about anything. Bring a variety of adapters and simple tools. I once watched my colleague repair a broken pulse oximeter brought by the team with a pliers, duct tape and a swiss army knife.
Anesthesia equipment hazards are common while working in the developing world. You must be vigilant and prepared to prevent accidents and mishaps. A copy of my review article on “Anesthesia in Distant Places: Prevention of Anesthesia Mishaps” can be found here.